Initial Hand Surgery Consultation Note

Diagnosis And Treatment Summary

1. Left carpal tunnel syndrome
2. Right ring finger stenosing tenosynovitis (trigger finger)

Occupation

• Data entry clerk (right-hand dominant)

Diagnostic Studies

• Left wrist X-ray (RadNet Imaging, 10/10/2023): Unremarkable osseous structures.
• Bilateral wrist ultrasound (RadNet Imaging, 10/10/2023): Left median nerve enlargement at the carpal tunnel inlet (cross-sectional area 14 mm²). Thickening of the right ring finger A1 pulley with focal flexor tendon hyperemia.

Past Medical History

• Medical history: T2DM, HTN, hypothyroidism
• Surgical history: Laparoscopic cholecystectomy (2015)
• Family history: Maternal OA; paternal T2DM
• Medications: metformin (Glucophage®) 500 mg PO BID, lisinopril (Prinivil®) 10 mg PO daily, levothyroxine (Synthroid®) 50 mcg PO daily
• Social history: Never smoker, rare alcohol use, lives with spouse
• Allergies: Penicillin (urticaria)

History Of Present Illness

• 54-year-old female (MRN: 849-201-74) referred for evaluation of progressive left hand paresthesias over 6 months and painful catching of the right ring finger for 3 months. Left hand symptoms are worse at night, frequently waking her from sleep. Right ring finger locks in flexion, requiring passive extension with the contralateral hand.
• Associated nocturnal paresthesias in the left thumb, index, and middle fingers, alongside subjective weakness when gripping objects. Denies cervical radiculopathy or recent trauma.

Physical Examination

• BP 128/78 mmHg, HR 72 bpm, RR 14/min, Temp 36.8 °C, SpO2 99 % on RA.

• Alert and oriented x3, NAD.

  Neurological: Light-touch sensation is preserved in the median, radial, and ulnar nerve territories of the hand and all digits. The Katz hand diagram demonstrates the classic symptom pattern. Motor function is intact in the IO/OP/EPL/FDP-index. Although sensation is intact, the patient reports subjective reduction in the median distribution, with positive Tinel and median-nerve compression tests and swelling over the distal volar forearm and wrist on the left. There is no intrinsic or thenar wasting. Symptoms increase with sustained repetitive gripping. Two-point discrimination exceeds 7 mm in the median distribution compared with 5 mm in the ulnar distribution.

  Musculoskeletal System Exam: The hand, wrist, and elbow have preserved extensor and flexor function. No stiffness is evident at the MP, PIP, or DIP joints, and no extensor lag is present at those joints. There are no boutonniere, swan-neck, or mallet deformities. Composite grip is full, and wrist and elbow movement remains within the physiologic range.

  Examination of the affected right ring finger shows a palpable, tender nodule over the A1 pulley, which is itself painful. A substantial mismatch is present between active and passive motion. There is a mild PIP flexion contracture and a subtle palmar nodule compatible with palmar fascial fibromatosis.

Diagnostic Studies

• Left wrist X-ray (RadNet Imaging, 10/10/2023): No fracture, malalignment, dislocation, or other osseous abnormality is seen. The radiographs were obtained because of trauma and pain.
• Bilateral wrist and hand ultrasound (RadNet Imaging, 10/10/2023): Confirmed left median nerve entrapment and right ring finger A1 pulley thickening without tendon tear.

Impression

• Left carpal tunnel syndrome, moderate
• Right ring finger stenosing tenosynovitis (trigger finger)

Management Plan

• Order upper extremity electrodiagnostic studies (EMG/NCS) to quantify severity of left median neuropathy prior to potential surgical release.
• Administered right ring finger A1 pulley corticosteroid injection today using triamcinolone acetonide (Kenalog®) 10 mg and lidocaine (Xylocaine®) 1 % 1 mL subcutaneously without complication. Provided nocturnal neutral wrist splint for the left wrist and naproxen (Naprosyn®) 500 mg PO BID PRN pain.
• Counselled on glycemic control optimization, steroid flare expectations, and signs of infection. Referred to hand therapy for right ring finger passive range-of-motion exercises. Follow up in 6 weeks to review EMG/NCS results and assess response to injection.
• Modified duty: limit repetitive forceful gripping and keyboarding to 30-minute intervals with 5-minute rest breaks for the next 4 weeks.

I spent more than 45 minutes consulting with this patient across face-to-face and non-face-to-face activities. More than half of the face-to-face time involved counselling and coordinating care. This work included reviewing the patient’s intake form, gathering further history during the visit, carrying out an examination appropriate to the reported symptoms and concerns, explaining and discussing the condition and recommended treatment, reviewing available results and orders for investigations, medications, and procedures, and carefully recording these findings and recommendations in the electronic health record.

Arthur Pendelton, M.D.

Disclaimer: The dictated material was transcribed using voice-recognition software. Although it was reviewed, it may contain errors and/or omissions.